Notes: All fields with the asterisk (*) are required. All requests for new service at an existing location have 5 to 7 business days to be completed. New Services will not be connected on Holidays or weekends.

Today's Date:

Date Service is Desired:

*

Type of Request:

*

Type(s) of Service:

ElectricWater*

First Name:

*

Last Name:

*

SSN:

--*

Drivers License #:

*

License State:

Birth Date:

Employer:

2. Do you need Area Lightsat the location of service? (Type YES or NO)

*

3. What type of service is required? (SINGLE PHASE/THREE PHASE)

Billing AddressPlease enter the address where bills should be sent:

Street Address/P.O. Box:

*

City:

*

State:

*

Zip Code:

*

Service AddressPlease enter the street address where service is required:

Check here if same as Mailing Address

Service Address:

Service Type (Construction Required or Existing Service):

*

E-mail:

*

Confirm E-mail:

*

Home Phone:

--*

Cell Phone:

--

Busniess Phone:

--*

Spouses Name:

Spouses SSN:

--

Co Applicant Driver's License:

Co Applicant License State:

Co Applicant Birth Date:

Co Applicant Employer:

Spouses Drivers License #:

Spouses Date of Birth:

Spouses Email Address:

Spouses Phone:

Sign Up for Online Bill Pay

Our members have the flexibility of managing their account information online to pay their bill, update account information and more. To sign up for an Online account, please specify an Internet Password and Password Hint.

ELECTRIC SERVICE APPLICANTS: I hereby completed this application and agree to purchase electric service from Mid-South Electric Cooperative Association upon the following terms and conditions. I have read and understand the applicable Electric Service Agreement. By checking this box, I agree to a credit check to determine deposit amount. I understand that I will receive a bill for services, per the billing option selected on this application. Pay-As-You-Go Service Agreement (For members that want to sign up for Pay-As-You-Go Service - residential electric members only).

WATER SERVICE APPLCIANTS: I hereby completed this application and agree to purchase water service from Mid-South Electric Cooperative Association upon the following terms and conditions. I have read and understand the applicable Water Service Agreement. By checking this box, I agree to a credit check to determine deposit amount. I understand that I will receive a bill for services, per the billing option selected on this application.

Once you submit the application, you will receive a confirmation email. You must select the link provided in the e-mail to confirm your request and pay the required fee and deposit (if any). Service will not be connected until all fees are paid. You can also call us @ 1-888-525-6677 or come by one of our three offices to makes your payment. CLICK HERE to get the Map and Mailing address of our three office locations.